Diagnosis method of hepatic steatosis using biochemical markers

ABSTRACT

The present invention is drawn to a new diagnosis method for detecting the extent of hepatic steatosis in a patient, in particular in a patient who suffers from a disease involving hepatic steatosis, or who already had a positive diagnosis test of liver fibrosis and/or presence of liver necroinflammatory lesions, by using the serum concentration of easily detectable biological markers. The invention is also drawn to diagnosis kits for the implementation of the method.

FIELD OF THE INVENTION

The present invention is drawn to a new diagnosis method for detecting the extent of hepatic steatosis in a patient, in particular in a patient who suffers from a disease involving hepatic steatosis or who already had a positive diagnosis test of liver fibrosis and/or presence of liver necroinflammatory lesions, by using the serum concentration of easily detectable biological markers. The invention is also drawn to diagnosis kits for the implementation of the method.

BACKGROUND OF THE INVENTION

Fatty liver, also named hepatic steatosis, is defined as an excessive accumulation of fat in hepatocytes (Bravo A A, et al. N. Engl. J. Med. 2001:344; 495-500; Angulo P. N. Engl. J. Med. 2002 Apr. 18; 346(16):1221-31). Fatty liver disease involves the accumulation of triglycerides in hepatocytes, necrosis of hepatocytes, inflammation (Day C P. Best Pract. Res. Clin. Gastroenterol. 2002; 16:663-78; Browning J D, Horton J D. J. Clin. Invest. 2004; 114:147-52), small hepatic veins obliteration and often fibrosis with sometimes progression to cirrhosis, hepatocellular cancer and liver-related death (El-Serag H B, et al. Gastroenterology 2004; 126:460-468, Dam-Larsen S, et al. Gut 2004; 53:750-5).

Worldwide the prevalence of hepatic steatosis is very high, associated with several factors such as alcohol, diabetes, overweight, hyperlipidemia, insulin resistance, hepatitis C genotype 3, abetalipoproteinemia and some drugs (Bellentani S, et al. Ann. Intern. Med. 2000; 132:112-7; Levitsky J, Mailliard M E. Semin. Liver Dis. 2004; 24:233-47).

Non-alcoholic fatty liver disease (NAFLD), is an adaptive response of the liver to insulin resistance that can trigger non-alcoholic steatohepatitis (NASH), which can itself induce a fibrogenic response that can result in cirrhosis (Day C P. Best Pract. Res. Clin. Gastroenterol. 2002; 16:663-78).

In patients with alcoholic liver disease (Sorensen T I, et al. Lancet. 1984; 2:241-4), chronic hepatitis C (Fabris P, et al. J. Hepatol. 2004; 41:644-51), and perhaps in hepatitis B (Phillips M J, et al. Am. J. Pathol. 1992; 140:1295-308), the presence of hepatic steatosis is also associated with fibrosis progression, with or without associated necroinflammatory lesions (alcoholic or viral hepatitis).

There is no standard recommendation for the diagnosis of hepatic steatosis. The usual recommendation is to measure GGT and ALT and to perform liver biopsy for the grading and staging (Bellentani S, et al. Ann. Intern. Med. 2000; 132:112-7; Levitsky J, Mailliard M E. Semin. Liver Dis. 2004; 24:233-47; Bravo A A, et al. N. Engl. J. Med. 2001:344; 495-500). As liver biopsy is still an invasive and costly procedure, with a potential sampling error, it could be advantageous to have a fast and easy to perform test that would give a good predictive value of the level of hepatic steatosis in the patient.

For the diagnosis of fibrosis, non-invasive FibroTest (FT) (Biopredictive, Paris France, U.S. Pat. No. 6,631,330) has been validated as surrogate marker in chronic hepatitis C (Poynard T, et al. Comp Hepatol. 2004; 3:8) and B (Myers R P, et al. J. Hepatol. 2003; 39:222-30) and recently in alcoholic liver disease (Callewaert N, et al. Nature Med 2004; 10; 1-6; Naveau S, et al. Clin Gastroenterol Hepatol in press).

So far, however, no study has demonstrated that a single or a panel of biomarkers can be used as an alternative to liver biopsy for the diagnosis of hepatic steatosis in the most common causes: alcohol, viral hepatitis and NAFLD.

There is therefore a need to develop a diagnosis method that would give a good predictive value of the extent of hepatic steatosis in a patient, and that would be reliable enough to reduce the need of liver biopsy. This method would be particularly advantageous for a patient who suffers from a disease involving hepatic steatosis or who already had a positive diagnostic test of liver fibrosis or necroinflammatory lesions, to adapt the treatment to his precise disease.

SUMMARY OF THE INVENTION

The present invention provides a method of diagnosis that assesses prospectively the predictive value of a combination of simple serum biochemical markers for the diagnosis of hepatic steatosis, in particular in the liver of a patient who suffers from a disease involving hepatic steatosis or who already had a positive diagnosis test of liver fibrosis and/or presence of liver necroinflammatory lesions. With the reach of high positive predictive values (prediction of significant hepatic steatosis) or negative predictive values, the number of biopsy indications could be reduced. This could be useful for patients and society in order to reduce the cost and the risk of liver biopsies.

DESCRIPTION OF THE FIGURES

FIG. 1: Flow chart of patients analyzed and included in the training and validation groups.

FIG. 2: Relationship between SteatoTest, GGT (IU/L) and ALT (IU/L) and the grade of liver steatosis.

Notched box plots showing the relationship in the training group (FIG. 2A); in validation group 1, HCV patients before treatment (FIG. 2B); in validation group 2, cured HCV patients (FIG. 2C); in validation group 3, alcoholic liver disease (FIG. 2D); and in controls, healthy volunteers fasting and non-fasting and non-fasting blood donors (FIG. 2E).

The horizontal line inside each box represents the median and the width of each box the median±1.57 interquartile range/√{square root over (n)} to assess the 95% level of significance between group medians. Failure of the shaded boxes to overlap signifies statistical significance (P<0.05). The horizontal lines above and below each box encompass the interquartile range (from 25, to 75^(th) percentile), and the vertical lines from the ends of the box encompass the adjacent values (upper: 75^(th) percentile plus 1.5 times interquartile range, lower 25^(th) percentile minus 1.5 times interquartile range). In validation group 3, almost all patients had steatosis and group S0 and S1 were combined.

FIG. 3: Relationship between SteatoTest, GGT (IU/L) and ALT (IU/L) and the grade of liver steatosis in the integrated database combining controls, training group and validation groups.

Failure of the shaded boxes to overlap signifies statistical significance between medians (P<0.05). There was a significant difference between all grades by Tukey-Kramer multiple comparison test for all pairwise differences between means (P<0.05).

For GGT and ALT there was no significant difference between “No steatosis” and “<5%” and between “5-33%” and “33-100%”. For ALT there was also no significant difference between “No steatosis” and “5-33%”, “<5%” and “5-33%”.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention is therefore drawn to a method for diagnosis of hepatic steatosis in a patient or from a serum or a plasma sample from a patient, comprising the steps of:

a) studying 5 biochemical markers by measuring the values of their concentration in the serum or plasma of said patient, wherein said markers are:

-   -   ApoA1 (apolipoprotein A1),     -   alpha.2-macroglobulin,     -   ALT (alanine aminotransferase),     -   GGT (gammaglutamyl transpeptidase), and     -   Triglycerides;         b) studying one clinical marker chosen in the group constituted         of the body mass index (Weight/Height²), the waist measurement,         and the (waist measurement/hip measurement) ratio;         c) combining said values through a logistic function including         said markers in order to obtain an end value, wherein said         logistic function is obtained through the following method:         i) classification of a cohort of patients in different groups         according to the extent of their disease;         ii) identification of factors which differ significantly between         these groups by unidimensional analysis;         iii) logistic regression analysis to assess the independent         discriminative value of markers for the diagnosis of hepatic         steatosis;         iv) construction of the logistic function by combination of         these identified independent factors; and         d) analyzing said end value of said logistic function in order         to determine the presence of hepatic steatosis in said patient.

Hepatic steatosis may be associated with several factors such as alcohol, diabetes, overweight, hyperlipidemia, insulin resistance, hepatitis C genotype 3, abetalipoproteinemia and some drugs. In particular, the present invention is directed to the diagnosis of both alcoholic and non-alcoholic steatosis.

By definition the best index (“Steatosis score”) in term of discrimination was the logistic regression function combining the independent factors.

The logistic function is obtained by combining the relative weight of each parameter, as individually determined in the logistic regression, with a negative sign when the markers harbor a negative correlation with the stage of hepatic steatosis. Logarithms are used for markers whose values have a very large range.

The quality of the logistic function is analyzed with the aid of a Receiver Operating Characteristic (ROC) curve that is obtained depending on the threshold desired for the diagnosis. The way of obtaining the ROC curve is described in the examples. In the present invention, the classification of the patients was done according to the different grades of hepatic steatosis (none=0%, mild=1-5%, moderate=6-32%, and (marked and severe)=33-100%, wherein each percentage refers to the percentage of hepatocytes involved in steatosis), but it could be changed if diagnosis of patient only with an marked or severe grade was intended. This would lead to another ROC curve.

The diagnosis of the presence or absence hepatic steatosis in the patient can be further refined by the data concerning the expected prevalence of hepatic steatosis in the population.

The logistic function may further comprise other clinical or biochemical markers. In a preferred embodiment, the logistic function also comprises the age and gender of the patient. In another embodiment, the logistic function may also comprise other biochemical markers, such as total bilirubin, haptoglobin, AST (aspartate aminotransferase), glucose, and (cholesterol or HDL-cholesterol). Preferably, the logistic function will comprise at least 1 or 2, more preferably 3 to 5 of these other biochemical markers. Most preferably, the logistic function may also comprise total bilirubin, haptoglobin, glucose, and cholesterol. The biochemical markers that are dosed in step a) of the method according to the present invention are “simple” biochemical markers, which means that they are easily dosed with methods already known in the art (chromatography, electrophoresis, ELISA assay . . . ).

The different coefficients used for the values obtained for the different markers in the logistic function can be calculated through statistical analysis, as described in the examples.

In particular, a suitable logistic function that can be used for the implementation of the method of the invention is as follows:

f=a1−a2.[Age(years)]+a3.[ApoA1 (g/L)]−a4 [Body Mass Index (Weight/Height²)]+a5.Log[.alpha.2-macroglobulin (g/L)]−a6.Log[ALT (alanine aminotransferase)(IU/L)]−a7.Log[total bilirubin (μmol/L)]−a8.[cholesterol (mmol/L)]−a9.Log[GGT (gammaglutamyl transpeptidase)(IU/L)]−a10. [glucose (mmol/L)]−a11.Log[Haptoglobin (g/L)]−a12.[triglycerides (mmol/L)]+a13.[Gender (female=00, male=1)], with

a1 comprised in the interval of [6.68805−x %; 6.68805+x %], a2 comprised in the interval of [1.55337E-02−x %; 1.55337E-2+x %], a3 comprised in the interval of [1.161531−x %; 1.161531+x %], a4 comprised in the interval of [0.11889−x %; 0.11889+x %], a5 comprised in the interval of [1.74791−x %; 1.74791+x %], a6 comprised in the interval of [0.96453−x %; 0.96453+x %], a7 comprised in the interval of [0.11958−x %; 0.11958+x %], a8 comprised in the interval of [0.68125−x %; 0.68125+x %], a9 comprised in the interval of [1.17922−x %; 1.17922+x %], a10 comprised in the interval of [1.46963−x %; 1.46963+x %], a11 comprised in the interval of [0.34512−x %; 0.34512+x %], a12 comprised in the interval of [1.17926−x %; 1.17926+x %], and a13 comprised in the interval of [0.35052−x %; 0.35052+x %].

An “interval of [a−x %; a+x %]” means an interval of [(100−)/100.a; (100+x)/100.a]. Preferably, x is at most 90, 80 or 70, more preferably at most 60, 50, or 40, even more preferably at most 30, 20, 10 or 5. All a_(i) coefficients are truncated to a number of 5 decimals. For instance, for x equal to 90, a13 is comprised in the interval of [0.03505; 0.66598].

Indeed, the numerical definitions for the coefficients in the different functions can vary depending on the number and characteristics of the patients studied. Therefore, the value given for the coefficients of the different markers have to be interpreted as capable to being slightly different, without reducing the scope of the invention.

A specific usable function, when x is equal to zero, is:

f=6.68805-1.55337E-2.[Age (years)]+1.161531.[ApoA1(g/L)]-0.11889.[Body Mass Index (Weight/Height²)]+1.74791.Log[.alpha.2-macroglobulin (g/L)]-0.96453.Log[ALT (alanine aminotransferase) (IU/L)]−0.11958.Log[total bilirubin (μmol/L)]−0.68125.Log[cholesterol (mmol/L)]−1.17922.Log[GGT (gam maglutamyl transpeptidase) (IU/L)]−1.46963.Log[glucose (mmol/L)]−0.34512.Log[Haptoglobin (g/L)]−1.17926.Log[triglycerides (mmol/L)]+0.35052. [Gender (female=0, male=1)].

Depending on the end value obtained by the analysis of biological markers values with the logistic function, it is possible to draw conclusions about the presence or absence of hepatic steatosis for the patient. It is also possible to conclude about the grade of hepatic steatosis, by taking said grade as the threshold in the drawing of the ROC curve.

In certain embodiments, the invention thus concerns a method as previously described, wherein the end value of the logistic function is further used for the diagnosis of hepatic steatosis grade. The different grades of hepatic steatosis are defined according to histological features of liver biopsies. A more precise definition of hepatic steatosis grades is provided in Example 1.

The method according to the invention may further comprise a step of prediction of the evolution of the disease, based on the hepatic steatosis grade deducted from the end value of the logistic function. In particular, a Steatosis score at the 0.30 cut off has a very high sensitivity ranging from 85% to 100% according to different groups (Table 4) and a Steatosis score at the 0.70 cutoff has a very high specificity ranging from 83% to 100%. Furthermore as already demonstrated for Fibrotest (Poynard 2004 Clin Chem 2004) many of the discordances between Steato-score and biopsy were due to error of the biopsy (small sample size). It is expected that the method of the invention will reduce the need of liver biopsy by more than 80%. For the first time, a clinician can have an estimate of major histological features leading to cirrhosis or explaining liver tests abnormalities: Steatosis score for steatosis, Fibrosis score (FibroTest, Biopredictive, Paris, France) for fibrosis, Activity score (ActiTest, Biopredictive, Paris, France) for the necrotico-inflammatory features of chronic hepatitis C and B. Biopsy should be indicated only in second line in case of non interpretable components as described for the Fibrosis score (FibroTest), i.e acute inflammation, Gilbert syndrome or hemolysis (Poynard Clin Chem 2004).

According to the invention, the hepatic steatosis grade deducted from the end value of the logistic function can also be very valuable for the physician to choose a suitable treatment for the patient, according to the stage of the disease.

Also, said hepatic steatosis grade may be used by the physician to decide whether to perform a liver biopsy on the patient or not.

Depending of the prevalence of hepatic steatosis in the population of patients that are consulting, the data obtained with the method of the invention can be used to determine the need to perform a liver biopsy on the patient. It is expected that the method of the invention will reduce the need of liver biopsy by around 80%.

The method of the invention is intended to be used for patients suffering of any disease involving hepatic steatosis, that could develop to cirrhosis. By a “disease involving hepatic steatosis” is meant any disease that may lead to the development of hepatic steatosis. In particular, the method of the invention is advantageously performed for detecting hepatic steatosis in patients suffering from a disease included in the group consisting of hepatitis B and C, alcoholism, hemochromatosis, metabolic disease, diabetes, obesity, autoimmune hepatitis, primary biliary cirrhosis, .alpha.1-antitrypsin deficit, Wilson disease.

The method of the invention is particularly intended to be used for a patient who was already subjected to a diagnosis test of liver fibrosis and/or presence of liver necroinflammatory lesions.

More preferably, the method of the invention is intended to be used for a patient who was already subjected to a FibroTest/Acti-Test diagnostic test, as described in U.S. Pat. No. 6,631,330, which is herein incorporated by reference.

The invention is also drawn to a kit of diagnosis of hepatic steatosis in a patient, comprising instructions allowing to determine the presence or absence of hepatic steatosis in said patient, after dosage of biochemical markers.

The instructions may comprise the logistic function that has to be used after determination of the dosage of the biochemical markers. It can appear as a printed support as well as a computer usable support, such as a software. The instructions may also comprise the ROC curve depending of the threshold that is looked for, to allow the analysis of the end data obtained from the logistic function. They may also comprise different tables that allow to obtain the predictive values, depending of the expected prevalence of hepatic steatosis in the patient population.

The diagnosis kit according to the present invention may also contain elements allowing the dosage of the biological markers of interest.

Said diagnosis kit may also contain instructions for the quantification of hepatic steatosis different grades (none=0%, mild=1-5%, moderate=6-32%, marked=33-66% and severe=67-100%), and other intermediate grades.

The method of the invention can easily be automated, the dosage of the markers being performed automatically, the data being sent to a computer or a calculator that will calculate the value of the logistic function and analyze it with the aid of the ROC curve, and eventually the prevalence of hepatic steatosis in the patient population. The data obtained by the physician is therefore more easily interpretable, and will allow for an improvement in the process for deciding the need of a biopsy or the adequate treatment to prescribe.

The following examples are meant to describe an aspect of invention, and give the methodology in order to repeat the method of the invention, but shall not be limiting the invention.

EXAMPLES Example 1 Patients and Methods 1.1. Patients

Consecutive patients with available serum, a consistent liver biopsy and a duration of time between serum and biopsy shorter than 3 months were included (FIG. 1). Non-inclusion criteria included non-available serum, and non-available biopsies and patients because biopsy and serum were collected more than 3 month apart. The analysis was performed on a first group (training group) and validated on 3 different groups (validation groups). Training group patients were retrospectively included for this specific analysis, but have been analyzed in previous prospective validation studies of Fibrotest between September 2000 and August 2004 (Poynard T, et al. Comp. Hepatol. 2004; 3:8; Myers R P, et al. J. Hepatol. 2003; 39:222-30; Ratziu V, et al. Hepatology 2003; 38:510 A). All were inpatients hospitalized in the Department of Hepato-Gastroenterology of Groupe Hospitalier Pitié-Salpêtrière for NAFLD, hepatitis C, B, and alcoholic liver disease.

Validation group 1 patients (hepatitis C patients) were retrospectively analyzed from a study of hepatic steatosis in patients with chronic hepatitis C (Poynard T, et al. Hepatology. 2003; 38:75-85). For this purpose, previously non-treated patients of a prospective multicentre randomized trial of PEG-IFN and Ribavirin were included. The biomarkers and the biopsy results at baseline were used.

Validation group 2 patients (former Hepatitis C with undetectable HCV patients) were the patients of the same randomized trial as in validation group 1 (Poynard T, et al. Hepatology. 2003; 38:75-85), who have been “cured” with sustained virologic response, meaning that HCV RNA is undetectable 24 weeks after the end of the treatment. The biomarkers and the biopsy results performed 24 weeks after the end of the treatment were used. This group has been considered as a validation group of NAFLD because possible viral steatosis has been cured by the treatment (Poynard T, et al. Hepatology. 2003; 38:75-85).

Validation group 3 patients (alcoholic liver disease patients) were retrospectively included for this specific analysis, but were prospectively included between 1998 and 2000 in a cohort of alcoholic patients for which one primary endpoint was the identification of biochemical markers. The details of this cohort have been recently published in a validation study of FibroTest (Naveau S, et al. Clin. Gastroenterol. Hepatol. 2005 in press). All were inpatients hospitalized in the Hepato-Gastroenterology Department of Hôpital Antoine Béclère for complications of alcoholic liver disease.

Patients' characteristics of the different groups are listed in Table 1.

TABLE 1 Characteristics of included patients Validation Validation Validation Training group 1 group 2 group 3 group HCV HCV cured Alcoholic liver disease Characteristics Number of patients 310 171 201 62 Age at biopsy (years) 48.9 (12.4) 44.1 (7.2) 43.6 (8.0) 46.6 (9.8) Male 201 (65%) 111 (65%) 122 (61%) 47/62 (76%) Female 109 (35%) 60 (35%) 79 (39%) 15 (24%) BMI (kg/m2) 25.4 (5.1) 27.7 (5.0) 26.5 (4.8) 24.2 (4.1) Biopsy quality Length 17.0 (6.2) 16.6 (15.5) 17.0 (8.2) 13.5 (6.8) Length >= 15 mm 205 (67%) 82 (48%) 96 (48%) 15 (24%) Number of fragments 2.5 (2.3) — — 1.9 (1.6) One fragment 128/278 (46%) — — 37 (60%) Duration biopsy-serum, mean (days range) 1 (0-30) 40 (0-90) 11 (0-45) 7 (0-14) Liver Risk factor HCV 211 (68%) 171 (100%) 0 (0%) 0 (0%) HBV 18 (6%) 0 (0%) 0 (0%) 0 (0%) NAFLD 69 (22%) 0 (0%) 0 (0%) 0 (0%) ALD 12 (4%) 0 (0%) 0 (0%) 0 (0%) Daily alcohol >= 50 g/day 34/236 (14%) 0 (0%) 0 (0%) 62 (100%) Cured HCV infection 0 (0%) 0 (0%) 201 (100%) 0 (0%) Metabolic factor BMI >= 27.0 92 (30%) 88 (51%) 77 (38%) 14 (23%) Glucose >= 6.0 mmol/L 63 (20%) 30 (18%) 27 (13%) 20 (32%) Triglycerides >= 1.7 mmol/L 67 (22%) 36 (21%) 54 (27%) 20 (32%) Cholesterol >= 6.0 mmol/L 61 (20%) 12 (7%) 26 (13%) 23 (37%) Metabolic factor: number per patient None 132 (43%) 60 (35%) 96 (48%) 17 (27%) One 101 (33%) 64 (37%) 72 (36%) 20 (32%) Two 52 (17%) 39 (23%) 31 (15%) 19 (31%) Three 22 (7%) 8 (5%) 0 (0%) 5 (8%) Four 3 (1%) 0 (0%) 2 (1%) 1 (2%) Liver steatosis grade None (0%) 130 (42%) 58 (34%) 116 (58%) 2 (3%) Mild (Score 1-5%) 40 (13%) 68 (40%) 63 (31%) 2 (3%) Moderate (Score 6-33%) 69 (22%) 35 (20%) 17 (8%) 42 (68%) Marked (Score 34-66%) 36 (12%) 7 (4%) 4 (3%) 12 (19%) Severe (Score 67-100%) 35 (11%) 3 (2%) 1 (0.5%) 4 (7%) Liver Fibrosis stage at biopsy F0 No 62 (20%) 0 (0%) 16 (8%) 8 (13%) F1 Fibrosis without septa 127 (41%) 102 (60%) 136 (68%) 23 (37%) F2 Few septa 52 (17%) 39 (23%) 33 (16%) 11 (18%) F3 Many septa 36 (11%) 19 (11%) 9 (4%) 7 (11%) F4 Cirrhosis 33 (11%) 11 (6%) 7 (3%) 13 (21%) Markers (normal range) AST IU/L (17-27 female; 20-32 male) 83 (159) 82 (57) 23 (9) 89 (83) ALT IU/L (11-26 female; 16-35 male) 109 (114) 118 (94) 19 (10) 72 (88) Total bilirubin mol/L (1-21) 14.8 (26.2) 11.1 (4.8) 8.8 (4.6) 21.5 (19.6) GGT U/L (7-32 female; 11-49 male) 112 (183) 84 (96) 21 (18) 323 (443) 2 macroglobulin g/L (female 1 · 6-4 · 0; male 1 · 4- 2.4 (1.0) 3.1 (1.2) 2.0 (0.8) 1.8 (0.5) 3 · 3) Apo A1 g/L (1 · 2-1 · 7) 1.4 (0.3) 1.3 (0.3) 1.2 (0.3) 1.5 (0.5) Haptoglobin g/L (0 · 35-2 · 00)* 0.95 (0.57) 0.78 (0.45) 0.86 (0.43) 1.39 (0.63) Glucose (mmol/L) 5.5 (3.2) 5.4 (1.2) 5.3 (1.0) 5.8 (1.6) Cholesterol (mmol/L) 4.9 (1.3) 4.5 (1.0) 5.0 (1.0) 5.4 (1.9) Triglycerides (mmol/L) 1.5 (1.4) 1.4 (0.8) 1.6 (1.0) 1.9 (3.1) FibroTest 0.42 (0.28) 0.47 (0.26) 0.29 (0.20) 0.43 (0.28) SteatoTest 0.49 (0.25) 0.53 (0.22) 0.36 (0.22) 0.58 (0.25) Data are mean (SD) or proportion. AST = aspartate aminotransferase. ALT = alanine aminotransferase. GGT = glutamyl transpeptidase. ApoA1 = apolipoprotein a1.

A control group was also analyzed. It was constituted of fasting and non-fasting apparently healthy volunteers previously included in a validation of FibroTest (Munteanu M, et al. Comp. Hepatol. 2004; 3,3) and additional non-fasting blood donors.

1.2. Serum Markers

The 10 following biochemical markers were assessed for the different groups: ApoA1, ALT (alanine aminotransferase), AST (aspartate aminotransferase), alpha.2-macroglobulin, GGT (gammaglutamyl transpeptidase), total bilirubin, haptoglobin, cholesterol, glucose, and triglycerides.

These 10 biochemical markers include the 6 components of the FibroTest-ActiTest adjusted by age and gender (patented artificial intelligence algorithm U.S. Pat. No. 6,631,330) plus the AST, cholesterol, glucose, and triglycerides markers and the BMI.

FibroTest (Biopredictive, Paris, France; FibroSURE LabCorp, Burlington, N.C., USA) was determined as previously published (Poynard T, et al. Comp Hepatol. 2004; 3:8; Myers R P, et al. J. Hepatol. 2003; 39:222-30; Callewaert N, et al. Nature Med 2004; 10; 1-6; Naveau S, et al. Clin Gastroenterol Hepatol in press; Imbert-Bismut F, et al. Clin Chem Lab Med 2004; 42:323-33; Munteanu M, et al. Comp Hepatol 2004; 3:3).

The published recommended pre-analytical and analytical procedures were used (Poynard T, et al. Comp Hepatol. 2004; 3:8; Myers R P, et al. J. Hepatol. 2003; 39:222-30; Callewaert N, et al. Nature Med 2004; 10; 1-6; Naveau S, et al. Clin Gastroenterol Hepatol in press; Imbert-Bismut F, et al. Clin Chem Lab Med 2004; 42:323-33; Munteanu M, et al. Comp Hepatol 2004; 3:3).

In the training and control groups GGT, ALT, serum glucose, triglycerides, cholesterol, and total bilirubin were measured by Hitachi 917 analyzer or Modular DP analyzers (both Roche

Diagnostics Mannheim, Germany) using the manufacturer's reagents. Alpha2-macroglobulin, apolipoprotein A1, and haptoglobin were measured using an automatic nephelemeter BNII (Dade Behring; Marburg, Germany).

In validation groups 1 and 2, GGT, ALT, serum glucose, triglycerides, cholesterol, and total bilirubin were measured using Hitach 747 or 911 (Roche Diagnostics, Indianapolis, Ind., USA) using the manufacfurer's reagents. Apolipoprotein A1, alpha2-macroglobulin, and haptoglobin were determined in serum samples using an automatic nephelometer BNII (Dade Behring; Marburg, Germany).

In validation group 3, ALT, GGT, serum glucose, triglycerides, cholesterol, total bilirubin and haptoglobin were measured by autoanalyzer (Olympus AU 640 Automate) using manufacturer's reagents (Olympus, Rungis France); alpha2-macroglobulin and apolipoprotein A1 were measured using an automatic nephelometer (BNII, Dade Behring; Marburg, Germany).

All coefficients of variation assays were lower than 10%.

1.3. Histological Grading

Histological grading was performed based on liver biopsies. Common rules were applied in the different groups, and a single pathologist per group, unaware of patient characteristics, analyzed the histological features. Liver biopsy specimens were processed using standard techniques.

Hepatic steatosis was scored from 0 to 4 with a four grades scoring system: 0=no steatosis, 1 to 5%=mild, 6 to 32%=moderate, 33 to 66%=marked, 67-100%=severe, all percentages referring to the percentage of hepatocytes involved in steatosis (Poynard T, et al. Hepatology. 2003; 38:75-85). The main histological criterion was the presence of steatosis grade 2-4 (between 6 to 100%).

Example 2 Statistical Analysis

Statistical analysis used Fisher's exact test, the chi-square test, Student's t test, the Mann-Whitney test and variance analysis using the Bonferroni all-pair wise and Tukey-Kramer multiple-comparison tests to take into account the multiple comparisons and multiple logistic regression for multivariate analysis (Hintze J L. NCSS 2003 User Guide. Number Cruncher Statistical Systems 2003 software NCSS, Kaysville, Utah). The analysis was performed on a first group (training group) and validated on 3 different groups (validation groups 1, 2 and 3), in cohorts of patients as in Table 1.

According to the hepatic steatosis scoring system, patients were divided into several groups.

The primary outcome was the identification of patients with hepatic steatosis grade 2, 3 or 4 (moderate, marked or severe).

In a secondary analysis, patients were classified according to a 4 scale scoring system.

The first stage consisted of identifying factors which differed significantly between these groups by unidimensional analysis using the chi-square, Student t test or Mann-Whitney test.

The second stage consisted of logistic regression analysis to assess the independent discriminative value of markers for the diagnosis of fibrosis.

The third step was to construct an index combining these identified independent factors. By definition the best index (“Steatosis score”) in term of discrimination was the logistic regression function combining the independent factors. In all the following examples, the Steatosis score is further referred to as “SteatoTest score”. The SteatoTest score ranges from zero to 1.00, with higher scores indicating a greater probability of significant lesions.

The diagnostic values of the markers were assessed using sensitivities, specificities, positive (PPV) and negative predictive values (NPV), and the areas under the Receiver Operating characteristic (ROC) curves (Hintze J L. NCSS 2003 User Guide. Number Cruncher Statistical Systems 2003 software NCSS, Kaysville, Utah).

The respective overall diagnostic values were compared by the area under the ROC curves. The ROC curve is drawn by plotting the sensitivity versus (1-specificity), after classification of the patients, according to the value obtained for the logistic function, for different thresholds (from 0 to 1). It is usually acknowledged that a ROC curve the area under which has a value superior to 0.7 is a good predictive curve for diagnosis. The ROC curve has to be acknowledged as a curve allowing to predict the quality of a diagnosis method.

Areas under ROC curves were calculated using empirical non-parametric method. A sensitivity analysis was also performed to determine the accuracy of the markers for the primary outcomes according to biopsy sample size. For all analyses, two-sided statistical tests were used; a P-value of 0.05 or less was considered significant. Number Cruncher Statistical Systems 2003 software (NCSS, Kaysville, Utah) was used for all analyses (Hintze J L. NCSS 2003 User Guide. Number Cruncher Statistical Systems 2003 software NCSS, Kaysville, Utah).

These statistical analyses were performed separately for the different groups, as previously defined.

Example 3 Determination of the Logistic Function

The “SteatoTest score” is defined as the logistic regression function combining the independent factors that returns the best index in term of discrimination between the presence or absence of hepatic steatosis.

In Table 2 are given the characteristics of patients according to the presence of hepatic steatosis for each of the 10 biochemical markers, the FibroTest score, and the SteatoTest score, as well as their independent association with fibrosis (P value).

In the training group the most significant components associated with the presence of grade 2-4 steatosis in univariate analysis were BMI, age, ALT, AST, GGT, glucose, and triglycerides.

In logistic regression analysis the most significant components were BMI (OR=0.89 P=0.0002), GGT (OR=0.31 P=0.002), apolipoprotein A1 (OR=3.20 P=0.01), alpha2-macroglobulin (OR=5.74 P=0.02), ALT (OR=0.38 P=0.03) and triglycerides (OR=0.31 P=0.04).

In the validation group similar differences were observed, most significantly for BMI, GGT, ALT and triglycerides (Table 2).

TABLE 2 Characteristics of patients according to the presence of steatosis Steatosis Steatosis Training group Validation group 1 <5% n = 170 HCV pos Characteristic m (SD) >=5% n = 140 P value No n = 126 Yes n = 45 P value Demographics Age at biopsy, years 46.7 (12.4) 51.8 (12.1) 0.0004 43.7 (7.3) 45.2 (7.0) 0.28 Male gender 110 (55%) 91 (45%) 0.96 81 (64%) 30 (67%) 0.77 BMI 24 (4) 27 (6) <0.0001 27 (5) 31 (4) <0.0001 Biochemical markers α₂-macroglobulin, g/L 2.47 (1.00) 2.30 (1.04) 0.07 3.10 (1.23) 3.20 (1.24) 0.50 ALT, IU/L 104 (119) 115 (108) 0.02 46 (45) 61 (48) 0.003 AST, IU/L 83 (204) 83 (78) 0.01 80 (61) 88 (43) 0.01 Apolipoprotein A1, 1.46 (0.34) 1.42 (0.33) 0.30 1.27 (0.26) 1.20 (0.24) 0.18 g/L Haptoglobin, g/L 0.93 (0.60) 0.96 (0.52) 0.19 0.77 (0.45) 0.78 (0.44) 0.84 GGT, IU/L 83 (132) 147 (226) <0.0001 72 (85) 118 (116) 0.0007 Total bilirubin, 14.8 (31.4) 14.7 (17.8) 0.47 11.0 (5.0) 11.3 (4.1) 0.38 μmol/L Glucose mmol/L 5.1 (3.7) 5.9 (2.2) <0.0001 5.2 (0.9) 6.0 (1.8) 0.0007 Triglycerides mmol/L 1.24 (0.95) 1.88 (1.78) <0.0001 1.26 (0.72) 1.72 (1.0) 0.0008 Total cholesterol 4.8 (1.2) 5.1 (1.4) 0.10 4.5 (1.0) 4.4 (1.0) 0.10 mmol/L FibroTest 0.40 (0.29) 0.45 (0.28) 0.47 0.45 (0.26) 0.53 (0.24) 0.07 SteatoTest 0.38 (0.21) 0.62 (0.22) <0.0001 0.47 (0.21) 0.70 (0.16) <0.0001 Steatosis Steatosis Validation group 3 Validation group 2 Alcoholic liver disease HCV neg <5% n = 4 Characteristic No n = 179 Yes n = 22 P value m (SD) >=5% n = 58 P value Demographics Age at biopsy, years 43.7 (8.1) 43.1 (7.0) 0.7 38.0 (12.8) 47 (9.4) 0.16 Male gender 110 (62%) 12 (55%) 0.53 2 (50%) 45 (78%) 0.21 BMI 26 (4) 31 (6) <0.0001 22.9 (2.9) 24.3 (4.2) 0.49 Biochemical markers α₂-macroglobulin, g/L 2.08 (0.79) 1.73 (0.66) 0.06 2.12 (0.53) 1.81 (0.55) 0.26 ALT, IU/L 18 (9) 26 (9) <0.0001 35 (24) 74 (90) 0.10 AST, IU/L 23 (9) 25 (7) 0.06 74 (43) 58 (90) 1.00 Apolipoprotein A1, 1.16 (0.28) 1.07 (0.25) 0.2 1.67 (0.43) 1.48 (0.49) 0.49 g/L Haptoglobin, g/L 0.85 (0.41) 0.94 (0.56) 0.85 1.55 (0.92) 1.38 (0.62) 0.85 GGT, IU/L 20 (18) 28 (14) 0.0002 327 (184) 323 (323) 0.41 Total bilirubin, 8.9 (4.6) 8.1 (4.3) 0.3 28.5 (23.4) 21.1 (19.5) 0.28 μmol/L Glucose mmol/L 5.3 (1.0) 5.5 (0.8) 0.16 6.5 (2.2) 5.7 (1.6) 0.46 Triglycerides mmol/L 1.49 (0.98) 2.05 (1.22) 0.003 1.05 (0.51) 1.96 (3.15) 0.28 Total cholesterol 5.0 (1.0) 5.1 (0.9) 0.51 6.0 (1.38) 5.4 (2.0) 0.68 mmol/L FibroTest 0.29 (0.20) 0.26 (0.19) 0.46 0.43 (0.32) 0.43 (0.28) 0.79 SteatoTest 0.32 (0.20) 0.62 (0.17) <0.0001 0.44 (0.03) 0.59 (0.26) 0.21 All data are means (sd) and proportions (n [%]). ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, γ-glutamyl-transpeptidase. SteatoTest combines in a multivariate regression analysis adjusted for gender, age and body mass index: alanine and aspartate aminotransferases, alpha-macroglobulin, apolipoprotein A-I, haptoglobin, total bilirubin, and γ-glutamyl-transpeptidase

The best logistic function (SteatoTest score) combining 9 markers and age, gender and BMI was determined on the training group to be as follows:

f=6.68805-1.55337E-02.[Age(years)]+1.161531.[ApoA1 (g/L)]−0.11889.[Body Mass Index (Weight/Height²)]+1.74791.Log[.alpha.2-macroglobulin (g/L)]−0.96453.Log[ALT (alanine aminotransferase)(IU/L)]−0.11958.Log[total bilirubin (μmol/L)]−0.68125.Log[cholesterol (mmol/L)]−1.17922.Log[GGT (gammaglutamyl transpeptidase)(IU/L)]−1.46963.Log[glucose (mmol/L)]−0.34512.Log[Haptoglobin (g/L)]−1.17926.Log[triglycerides (mmol/L)]+0.35052.[Gender (female=0, male=1)].

This function was obtained on the training group by combining the relative weight of each parameter, as individually determined in the logistic regression, with a negative sign when the markers harbors a negative correlation with the stage of hepatic steatosis. Logarithms were used for markers whose values have a very large range.

The value of the SteatoTest score, combining 9 markers (alpha2-macroglobulin, ALT, apo A1, haptoglobin, GGT, and total bilirubin), adjusted by age, gender and BMI, had a high correlation with the presence or absence of hepatic steatosis, on the training sample as well as on validation samples (Table 2).

One of the major discoveries of the present work is the very significant improvement in the diagnostic value of steatosis when combining markers versus the classical routine test previously recommended such as GGT and ALT. The simple markers of insulin resistance such as BMI, glucose, triglycerides increased the diagnostic value of ALT and GGT. This had not been previously demonstrated in the different causes of liver steatosis. Furthermore, it was demonstrated for the first time that the diagnostic value of ALT was much greater than GGT for the diagnosis of steatosis. Interestingly also, the GGT value did not increase according to the severity of steatosis in comparison to ALT.

Example 4 Analysis of the Data 4.1 Fiability of the SteatoTest Score for the Diagnosis of Hepatic Steatosis.

Diagnostic values (areas under ROC curves) of the SteatoTest score for the different patients groups are displayed in Table 3. Sensitivity, specificity and positive and negative predictive values of the SteatoTest score with a cut-off of 0.30, 0.50, and 0.70 are displayed in Table 4.

TABLE 3 Values [Area under the ROC curves (AUROCs)] of Steatosis score, GGT and ALT for the diagnosis of steatosis, in training and validation groups Validation Validation Validation Training group 1 group 2 group 3 group HCV HCV Alcoholic AUROC (se) detectable Undetectable Liver Disease Diagnostic panel N = 310 N = 171 N = 201 N = 62 SteatoTest 0.79 (0.03)* 0.80 (0.04)£ 0.86 (0.03)$ 0.72 (0.05)** GGT 0.66 (0.03) 0.67 (0.05) 0.74 (0.05) 0.50 (0.09) ALT 0.58 (0.03) 0.62 (0.05) 0.79 (0.04) 0.66 (0.07) *Higher than GGT (p < 0.0001) and ALT (p < 0.0001) £Higher than GGT (p = 0.007) and ALT (p < 0.0001) $Higher than GGT (p = 0.02) **Higher than GGT (p = 0.002)

TABLE 4 Diagnostic value of Steatosis score for predicting hepatic steatosis greater than 5% Negative Positive Predictive Cut-off Sensitivity Specificity Predictive Value Value Training group Prevalence = 45% N = 310 SteatoTest 0.30 0.91 (127/140) 0.45 (77/170) 0.58 (127/220) 0.86 (77/90) 0.50 0.69 (97/140) 0.74 (126/170) 0.69 (97/141) 0.75 (126/169) 0.70 0.45 (63/140) 0.89 (152/170) 0.78 (63/81) 0.66 (152/229) GGT 50 IU/L 0.66 (92/140) 0.55 (94/170) 0.55 (92/168) 0.66 (94/142) ALT 50 IU/L 0.77 (108/140) 0.35 (60/170) 0.50 (108/218) 0.65 (60/92) Validation group1 Prevalence = 26% N = 171 SteatoTest 0.30 0.98 (44/45) 0.24 (30/126) 0.31 (44/140) 0.97 (30/31) 0.50 0.89 (40/45) 0.58 (73/126) 0.43 (40/93) 0.94 (73/78) 0.70 0.44 (20/45) 0.83 (105/126) 0.49 (20/41) 0.81 (105/130) GGT 50 IU/L 0.62 (28/45) 0.61 (72/126) 0.34 (28/82) 0.81 (72/89) ALT 50 IU/L 1.00 (45/45) 0.06 (8/126) 0.28 (45/163) 1.00 (8/8) Validation group2 Prevalence = 11% N = 201 SteatoTest 0.30 1.00 (22/22) 0.56 (100/179) 0.22 (22/101) 1.00 (100/100) 0.50 0.68 (15/22) 0.79 (142/179) 0.29 (15/52) 0.95 (142/149) 0.70 0.32 (7/22) 0.92 (165/179) 0.33 (7/21) 0.92 (165/180) GGT 50 IU/L 0.09 (2/22) 0.97 (174/179) 0.29 (2/7) 0.90 (174/194) ALT 50 IU/L 0.05 (1/22) 0.98 (176/179) 0.25 (1/3) 0.89 (176/197) Validation group3 Prevalence = 94% N = 62 SteatoTest 0.30 0.85 (49/58) 0.00 (0/4) 0.93 (49/53) 0.00 (0/9) 0.50 0.62 (36/58) 1.00 (4/4) 1.00 (36/36) 0.15 (4/26) 0.70 0.40 (23/58) 1.00 (4/4) 1.00 (23/23) 0.10 (4/39) GGT 50 IU/L 0.90 (52/58) 0.00 (0/4) 0.93 (52/56) 0.00 (0/6) ALT 50 IU/L 0.53 (31/58) 0.75 (3/4) 0.97 (31/32) 0.10 (3/30)

All the results show that the SteatoTest score can reach very high diagnostic values (area under the ROC curve, see Table 3), and high specificity, sensitivity and positive or negative predictive values for the diagnosis of hepatic steatosis (see Table 4).

The diagnostic value (area under the ROC curve) of the SteatoTest score was highly reproducible between the training group and validation groups 1, 2 and 3 (Table 3). The sensitivity was also quite reproducible between the training group and validation groups 1, 2 and 3 (Table 4). In addition, the sensitivities and specificities of the SteatoTest score observed in the different populations studied will probably increase in a more general population because of the excellent specificity observed in volunteers and blood donors (FIG. 2E), and because of the fact that the present studies have included a limited number of patients with several metabolic risk factors such as morbid obesity.

For some patients, the diagnoses of the presence of hepatic steatosis by biopsy and by the SteatoTest score were discordant. The cause of discordance between presence of >5% hepatic steatosis predicted by biochemical markers and biopsy was attributed according to respective risk factors of failure as previously detailed (Poynard T, et al. Clin. Chem. 2004; 50:1344-55). Significant discordance was defined as discordance in predicting 5>% hepatic steatosis (grades 2-4) and a 30% or greater difference in >5% hepatic steatosis percentage as predicted by the SteatoTest score or as observed in the biopsy sample. Risk factors of SteatoTest score failure were hemolysis, Gilbert's disease, acute inflammation and extra hepatic cholestasis. Risk factors of biopsy failure were biopsy size (less than 25 mm) and fragmentation (more than one fragment). Failure attributable to biopsy (false negative) was suspected when the biopsy was smaller than 15 mm and fragmented plus the presence of at least one metabolic risk factor.

In the training group there were 56 cases (18%) of significant discordance between steatosis percentage as predicted by ST and that observed in biopsy samples. Failure attributable to ST (false positive of ST) was suspected in one case that had acute drug hepatitis associated with chronic hepatitis B. Failure attributable to biopsy (false negatives of biopsy) was suspected in 16 cases with poor quality biopsy samples (median length 13 mm, 2 fragments) and at least one metabolic risk factor.

For the validation' groups, significant discordance was observed in 17 cases (16%) in group 1, 20 cases (10%) in group 2 and 13 cases (21%) in group 3. Significant discordance was observed more often in patients with extensive fibrosis (stage F3 or F4): 38 cases out of 135 (28%) versus 91 cases out of 609 (15% P=0.001).

Compared to the invasive and costly biopsy diagnosis, it is very important to notice that the method of the invention does not lead to a large number of undue treatments of patients or to the exclusion of patients in need of a treatment. The data presented in this application does strengthen the reliability of the method of diagnosis according to the present invention.

4.2 Comparison of the SteatoTest Score with Other Non Invasive Diagnosis Tests (FibroTest, GGT 50 IU/L et ALT 50 IU/L)

The results obtained with the SteatoTest score (using 9 biochemical parameters adjusted by age, gender and BMI) were compared to those obtained with the use of isolated markers such as GGT and ALT, which are usually considered to be useful markers to indicate the presence or absence of hepatic steatosis. The same standard cut-off value is used for GGT and ALT: 50 IU/L. Under said cut-off value, the diagnostic of hepatic steatosis is considered to be negative, over, it is considered to be positive.

The characteristics of patients according to the presence of hepatic steatosis for individual biochemical markers, the FibroTest, and the SteatoTest score are displayed in Table 2.

Compared with FibroTest, the SteatoTest score allows a much better discrimination between the presence or absence of hepatic steatosis in all groups analyzed, in particular for the training group and validation group 2 (Table 2).

Diagnostic values (areas under ROC curves) of the SteatoTest score, GGT 50 IU/L and ALT 50 IU/L for the diagnosis of the main end point (that is, grade 2-4 hepatic steatosis), are displayed in Table 3. The SteatoTest score has higher areas under ROC curves than GGT 50 IU/L in all groups analyzed, and that ALT 50 IU/L in the training group and validation group 1 (Table 3).

Sensitivity, specificity and positive and negative predictive values of the SteatoTest score with a cut-off of 0.30, 0.50, or 0.70, and of GGT 50 IU/L and ALT 50 IU/L are displayed in Table 4. For the diagnosis of grade 2-4 steatosis, a SteatoTest score with a 0.50 cut-off achieved a good sensitivity (0.69, 0.89, 0.68 and 0.62) and a good specificity (0.74, 0.58, 0.79, 1.00), according to training and validation groups respectively. Moreover, such a SteatoTest score with a 0.50 cut-off displays higher positive and negative values than GGT 50 IU/L and ALT 50 IU/L in all groups analyzed, excepted for the negative predictive value of ALT 50 IU/L in validation group 1.

In addition, concerning the discrimination between hepatic steatosis different grades, it is best achieved by the SteatoTest score, compared to GGT 50 IU/L and ALT 50 IU/L in all groups analyzed (FIG. 2).

The discrimination between hepatic steatosis different grades was also analyzed on an integrated base constituted of all the included subjects of the training group, the three validation groups and the control group (884 subjects).

There was a very significant overall correlation between the SteatoTest score and the steatosis grades from controls to “33-100%” (grades 3-4, see FIG. 3). For the SteatoTest score, there was a significant difference between all grades by Tukey-Kramer multiple comparison test for all pairwise differences between means (P<0.05). In contrast, for GGT and ALT, there was no significant difference between “No steatosis” (grade 0) and “<5%” (grade 1). For ALT, there was even no significant difference between “No steatosis” (grade 0) and “6-32%” (grade 2), “<5%” (grade 1) and “6-32%” (grade 2), and “6-32%” (grade 2) and “33-66%” (grade 3).

In conclusion, the present invention presents a combination of at least 5, preferably 9, biochemical markers, adjusted by age, gender and BMI, to be used for the detection of the presence or absence of hepatic steatosis. The markers used in the present invention had never been combined in such a way, particularly with the age, gender, and BMI of the patients to give such a good predictive value, as illustrated by the area under the ROC curve.

The diagnosis method of the invention can be analyzed automatically, after an automatic measurement of the values of the markers, and can advantageously be applied for patients with a hepatic steatosis involving disease to reduce the indication of liver biopsy. 

1.-10. (canceled)
 11. A kit for diagnosis of hepatic steatosis in a patient comprising: (a) instructions for determining the presence of hepatic steatosis in said patient: (b) reagents for measuring the serum values of the concentrations of 5 biochemical markers, wherein said markers are: ApoA1 (apolipoprotein A1) alpha2-macroglobulin ALT (alanine aminotransferase) GGT (gammaglutamyl transpeptidase), and triglycerides (c) optionally, at least one reagent for measuring the serums values of the concentrations of total bilirubin, haptoglobin, AST (aspartate aminotransferase), glucose, or (cholesterol or HDL-cholesterol). (d) instructions for using a logistic function that is used to combine said values with one clinical marker chosen in the group constituted of the body mass index (Weight/Height²), the waist measurement, and the (waist measurement/hip measurement) ratio, in order to obtain an end value.
 12. The kit of claim 11, further comprising an ROC curve.
 13. The kit of claim 11, further comprising tables that allow to obtain the predictive values, depending of the expected prevalence of hepatic steatosis in the patient population.
 14. The kit of claim 11, further comprising instructions for the quantification of hepatic steatosis different grades (none=0%, mild=1-5%, moderate-6-32%, marked=33-66%, and severe=67-100%), and other intermediate grades. 